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Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan Zoghbi Moderator : Dr. Nabil Naja Dar Al-Ajaza Al-Islamia.

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Presentation on theme: "Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan Zoghbi Moderator : Dr. Nabil Naja Dar Al-Ajaza Al-Islamia."— Presentation transcript:

1 Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan Zoghbi Moderator : Dr. Nabil Naja Dar Al-Ajaza Al-Islamia Hospital Beirut, Jan 2003 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

2 Challenges of Geriatrics in Primary Care
Short visit times Low reimbursement rates Multiple co-morbidities Needs of caregiver and patient Ever-expanding diagnostic and therapeutic options Cross cultural communication January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

3 Dar Al-Ajaza Al-Islamia Hospital in Beirut
KEYS TO SURVIVAL Time management You don’t have to do everything yourself Working knowledge of geriatric assessment tools Determine when to refer someone for comprehensive geriatric assessment January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

4 Overview and Learning Objectives
At the end of this lecture, you should be able to answer: Why is assessment important? What are some useful tools for Assessment? How can assessment be incorporated into a short visit? What are some strategies for making a visit more efficient? Is there any Evidence to support the use of Geriatric Assessment? January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

5 Why is assessment important?
Lebanese are aging !: 1972: ~ 4% 1996: ~ 7.5% 2000: 8.6% 2025: ~ 14% 2050: ~ 20% Life expectancy: 1950: 54 years 2002: ~ 70 years January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

6 Why is Assessment Important?
Americans are aging! 1998: Age 65+ numbered 34 million 2030: Age 65+ will number 70 million Largest increases in those over age 85 Older population more ethnically diverse Majority of elderly will be cared for by internists and family practitioners ACP 1998: “Internists should be measuring functional deficits and identifying dependency needs of older adults” January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

7 Why is Assessment Important?
“Usual” care may not meet elders’ needs The 80+ survey: 75% said MD unaware of social needs 37% said MD unaware of physical needs 42% said MD was unaware of their emotional needs 50% said Medical Care could be improved Patterson 1998 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

8 What is Geriatric Assessment?
Different models and definitions exist Geriatrics is often best practiced as an interdisciplinary team approach Evaluates different domains: medical, cognitive, psychological, social, physical Expands scope of interest to include caregiver and environment Emphasis on optimization of function and increase in active life expectancy January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

9 Active Life Expectancy at 75
Total Active Disabled White women Black women Black men White men Guralnik, NEJM, 1993 I try to make the point here that part of what we are trying to do in geriatrics is extend the period of active life expectancy January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

10 Dar Al-Ajaza Al-Islamia Hospital in Beirut
DOMAINS OF CGA MEDICAL COGNITIVE QUALITY OF LIFE FUNCTIONAL STATUS AFFECTIVE ENVIRONMENTAL SOCIAL SUPPORT ECONOMIC January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

11 Selected Tools for Assessment
Lachs: Simple screen Similar version validated by Moore and Siu in 1996 Good inter-rater reliability Easy to use 7-10 minutes to administer Can be administered by non-MD personnel UCSF version January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

12 Areas covered in Lachs Tool
Vision Hearing Incontinence Falls and Gait Upper extremity function Cognition ( 3 item recall) Depression Medications ADLs and IADLs January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

13 Underreporting Common
Underreporting of symptoms common in the elderly Many elderly attribute treatable symptoms to “aging” and stated “nothing can be done about it anyway” 1/2-1/3 of symptoms may go unreported to physicians So its important to do a “geriatric ROS” January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

14 Quick Clues to Dementia
About 2/3 of mild-moderate dementia missed by providers Content empty speech Loss of IADL function Inability to recall 3 items at 5 minutes Inability to draw clock Larson 1998, JAGS Siu 1991, Ann Int Med January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

15 Screening Tests for Dementia
Test & Result LR PTP given prevalence of: 3 item recall 2% 10% 50% recalls < recalls Clock Draw abnormal almost normal normal Siu, Ann Intern Med, 1991 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

16 Dar Al-Ajaza Al-Islamia Hospital in Beirut
The MMSE Well validated Good predictive accuracy Easy and relatively quick to administer “Cut off” usually cited as 24 Sensitivity 85% Specificity 90% Tombaugh JAGS 1992, Siu, Annals 1991 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

17 Dar Al-Ajaza Al-Islamia Hospital in Beirut
The MMSE: Limitations Education, cultural, and age biases Crum JAMA 1994 Score impacted by vision, literacy, depression. Floor and ceiling effects Best to use as one tool in evaluation January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

18 Falls and Gait Disorders
Falls and gait disorders are common among the elderly & are a major cause of morbidity and mortality 1/3 of elderly fall each year Major cause of NH placement Falls, mobility impairment, and functional impairment closely related January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

19 Falls and Gait Disorders
Fall History Assessment: Ask the Patient: Have you fallen in the past year? Gait Assessment Up and Go Test Rise from chair, walk 10 feet, turn around, walk back, sit down Timed Up and Go Test – normal less than 10 seconds Tinetti ( or POMA) Timed Up and Go: If greater than 30 seconds, only 23% independent in tub or shower, only 4% can climb stairs January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

20 BALANCE AND GAIT EVALUATION
Sitting, rising from a chair Immediate and prolonged standing balance Withstanding nudge on chest Standing balance with eyes closed TURNING BALANCE (360 degrees) Sitting down Gait observations Initiation of gait Step length, height, continuity, symmetry Walking stance Amount of trunk sway Path deviation Tinetti. Am J Med 1986; 80:429 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

21 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Why Assess Function? Medical conditions may present first (or only) as functional disturbances Functional loss highly impacts quality of life Functional losses may lead to further disability and institutionalization Functional losses impact patient and caregiver January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

22 Functional Impairments
ADLs Bathing Dressing Toileting Transfers Continence Feeding IADLs Using telephone Shopping Food preparation Housekeeping Laundry Transportation Medications Managing money January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

23 Difficulty with ADLs and IADLs by Age
US Census Bureau, 1990 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

24 Dar Al-Ajaza Al-Islamia Hospital in Beirut
AADLs Patient specific activities that can be used to detect subtle functional losses in high functioning patients Can be job or recreation oriented Socializing, playing bridge, working, playing golf, playing music, dancing, practicing law, flying a plane, gardening. January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

25 Other measures available
Upper extremity mobility Manual dexterity Lower extremity mobility Combination of both Balance and gait evaluation January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

26 Using Functional Information
Use functional status as baseline Use it to guide recommendations for exercises, PT, adaptive devices for impairments Consider home evaluation for highly impaired Potential marker of caregiver stress Useful for evaluating risk of & need for placement January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

27 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Depression Geriatric depression scale 30 item instrument Yes/no to series of questions 10-15 minutes, self or interviewer to administer Scores <9 less probability >11 higher likelihood >18 highest possibility Brink. Clin Gerontol 1982; 1:37 January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

28 Geriatric depression scale
Shorter version 15 item, less certain diagnostic accuracy SCORE: 0-5 NORMAL, >5 SUGGEST DEPRESSION >10 almost always depression Sheikh, Yesavage. Clin Gerontol. 1986; 5: January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

29 Disadvantage in frail elderly
Hard to administer with concomitant cognitive impairment Cornell scale 19 items caregiver is asked variety of questions Scores: 8-12 possible depression, >12 probable Useful screening for major depression in both demented and non-demented patients January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

30 Other psychiatric problems to look for
Delirium (confusion assessment method) Anxiety Hostility Psychosis Behavioral problems January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

31 Malnutrition risk factors
Chronic disease Poverty Social isolation Cognitive impairment Functional disability January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

32 Indicators of poor nutrition
Impaired wound healing Increased surgical complications Increased mortality January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

33 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Screening assessment WEIGHT <100 lbs IN AMBULATORY OLDER PATIENTS, NOT ALWAYS ACCURATE Weight loss > 10% body weight Physical findings Chelosis, glossitis, loss of subQ body fat, muscle, wasting, edema Lab Decreased serum albumin, lymphocytes<1000 Body mass index, mid arm circumference, triceps skin folds January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

34 Visual and hearing impairments
Visual impairment 13% older persons Hearing impairment Age 65-74: 25% Age >85: 50% Increase risk injury Increased disability in physical and psychosocial function Decreased quality of life January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

35 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Vision screening Sensitivity and specificity for screening tests by primary care Dr not established Limited accuracy of glaucoma screening Snellen test Specific questions regarding vision January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

36 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Hearing screening Hand held audioscope $500 40db TONES AT 500, 1000, 2000, 4000 hz Takes 90 seconds, 94% sensitive, 72% specific Increase accuracy with short questionnaire Whispered voice or finger rub Cheaper Subject to variation between examiners January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

37 Remember the caregiver!
80% of care of elderly is informal & unpaid High caregiver stress highly correlated with increased risk of institutionalization, excess caregiver mortality, abuse, and neglect Education & support of caregiver may be critical part of keeping your patient at home and safe Zarit Caregiver Burden Interview or question about caregiver stress (caregiver alone) Solutions: Respite, day care, support groups Remembering back to an earlier slide, about 1/2 of people age 85 and older need help with IADL’s, and 1/3 need help with BADLs. For these people, a caregiver is critical to their ability to stay home and not be placed in a nursing home. Although we aren’t technically the provider of the caregiver, to care for our patient we need to know how the caregiver is doing, and to provide help and support when necessary. In many cases, the caregiver is the best source of our history on the patient. Social workers can be invaluable in assisting us in this. Likewise, the frail person depends more on the safety of their environment than the robust person. Knowing when we can intervene to make the patient better, versus when we can only intervene to make the environment safer to compensate for the deficits of the person, is critical. Home evaluations can be a critical adjunct to an office visit for a frail older person. January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

38 Abuse and Neglect: Helpful Questions
S - Do you feel Safe at home? What Stress do you feel in your relationship? A - Do you feel Afraid or have you been Abused by any of your caregivers? F - Are there any Family or Friends that you could ask for help or support? E – Do you have a safe place to go in case of an Emergency? Is it an Emergency now? Remembering back to an earlier slide, about 1/2 of people age 85 and older need help with IADL’s, and 1/3 need help with BADLs. For these people, a caregiver is critical to their ability to stay home and not be placed in a nursing home. Although we aren’t technically the provider of the caregiver, to care for our patient we need to know how the caregiver is doing, and to provide help and support when necessary. In many cases, the caregiver is the best source of our history on the patient. Social workers can be invaluable in assisting us in this. Likewise, the frail person depends more on the safety of their environment than the robust person. Knowing when we can intervene to make the patient better, versus when we can only intervene to make the environment safer to compensate for the deficits of the person, is critical. Home evaluations can be a critical adjunct to an office visit for a frail older person. January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

39 Abuse and Neglect: Caregiver Risk Factors and Clues
Caregiver does not come to appointments Is concerned about medical costs History of substance abuse, mental health problems, conflicts with patient Dominates interview, won’t leave, won’t let patient talk Defensive, hostile, or indifferent Dependence on patient for income/housing Remembering back to an earlier slide, about 1/2 of people age 85 and older need help with IADL’s, and 1/3 need help with BADLs. For these people, a caregiver is critical to their ability to stay home and not be placed in a nursing home. Although we aren’t technically the provider of the caregiver, to care for our patient we need to know how the caregiver is doing, and to provide help and support when necessary. In many cases, the caregiver is the best source of our history on the patient. Social workers can be invaluable in assisting us in this. Likewise, the frail person depends more on the safety of their environment than the robust person. Knowing when we can intervene to make the patient better, versus when we can only intervene to make the environment safer to compensate for the deficits of the person, is critical. Home evaluations can be a critical adjunct to an office visit for a frail older person. January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

40 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Review medications Elderly use 3X more medications than younger patients Drug distribution, elimination, excretion, & pharmacodynamics altered in elderly ADR’s and drug-drug interactions increase markedly with # drugs used Medications linked to “reversible dementias”, falls, incontinence, hospitalizations, death January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

41 Nonadherance and # Drugs
Percent Adherence # of drugs January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

42 Reviewing Medications
Have patient bring in all medications, including OTC’s, herbs, dietary supplements Ask about other providers Consider home visit if high risk Eliminate questionable medications Simplify regimens or consider “Medi-sets”, visiting nurses, or involving caregiver For new medications, start low and go slow, but get there! January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

43 Practical Tips for Practicing Geriatrics in your Office
January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

44 Planning the initial office interview
Relaxed and efficient atmosphere Good acoustic conditions and no interruptions Efficient appointment system Wheel chair accessible Hearing device: amplifier and microphone Paper/plastic bag test (bring all meds) Obtain prior medical records January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

45 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Make Your Life Easier Send out pre-visit questionnaire (e.g., UCLA) Use brief screening tests (e.g. Lachs) or single questions when possible Use more detailed tests only when indicated Have forms handy Train nursing and ancillary staff to perform screening tests January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

46 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Interview techniques In clinic: obtain data at several appointments over time Introduce yourself Ask how the patient would like to be addressed Traditional “chief complaint” may not be appropriate for most older patients How can I help you today? Better than what seems to be the problem? January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

47 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Make Your Life Easier Discuss patient goals early Focus visit on patient’s goals and priorities, not you clinic’s quality improvement checklist Realize that patient’s goals and priorities may change over time Change your clinic’s quality improvement checklist to reflect the priorities of geriatrics! January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

48 History of the elderly patient
Patient profile, social history History of current problems Review of symptoms and systems Medical history Medication history Caregiver’s status Family history Functional history, ADLs’s Community services currently provided January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

49 Minimal social assessment
Content of average day for patient Abilities in ADL’s Suitability and safety of home Availability, attitude and health of caregivers and neighbors Services received and/or needed Transportation needs Financial status Occupational history and interests January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

50 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Agir The French experience Explore multiple aspects of social, cognitive, medical life. 17 items, 3 possibilities. 4 B or C required. January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

51 Indications for a home visit visit
Living alone, especially if recently bereaved or separated Mental impairment Major mobility problems Several risk factors for dependency History of falling or accidents Imminent institutionalization Recent hospital discharge, especially if recovery was incomplete January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

52 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Get Help! Involve social worker and other team members early When you are overwhelmed Consider home nursing visits Consider referral to “team geriatric program” Consider other community referrals (case management programs, etc.) January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

53 Geriatric Assessment:
The Evidence January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

54 Why use assessment instrument?
Research Clinical practice guide Screening (identify unrecognized disease) Case finding Monitor patients throughout course of disorder Follow response to treatment January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

55 Does Geriatric Assessment Improve Outcomes?
Results mixed in RCTs Most robust outcomes seen in studies with a intervention component and follow up Increased “case finding” with GA screens Less institutionalization noted in a meta-analysis of GA Less disability noted in study of home GA January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

56 Dar Al-Ajaza Al-Islamia Hospital in Beirut
Summary Aging is a big issue! Focus on function Consider caregivers and abuse Review medications Screen for geriatric syndromes: falls, incontinence, dementia, depression, hearing, vision, pain… Abbreviate and target PE and assessment tools when possible Get help, use a team when possible! January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

57 Dar Al-Ajaza Al-Islamia Hospital in Beirut
thank you January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut


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